1. Constipation Assessment

2. Constipation More common in people >65 26% men 34% women complain of constipation Related to low food intake, not fibre or fluid

3. Assessment Goals of assessment: make a diagnosis with a view to safely manage symptoms History Examination Investigations

4. Differential diagnosis Due to disease of anus/rectum/colon Due to systemic disease No structural or systemic disease Due to medication, immobility, environment

5. History Duration Bowel motions/week, consistency Straining/symptoms of rectal outlet delay Urine and faecal incontinence Abdo pain (?relieved by evacuation) Red flags: weight loss, rectal pain/bleeding Mood, cognition, diet

6. More History Past history Medication: laxatives now and past, analgesics, anticholinergics (include antidepressants, antipsychotics, antispasmodics, antihistamines) antihypertensives, anti-cancer drugs

7. What if limited history from patient? Caregivers Relatives Notes Bowel record

8. Frequency Consistency Associated symptoms Bristol stool charts

9. Examination 1 Abdominal examination appearance tenderness masses bowel sounds

10. Examination 2 Rectal examination Appearance of perineum Appearance of anus Perianal sensation Anal wink Anal tone Pain or tenderness Contents of rectum Wall smoothness, ?masses

11. Investigations Bloods (which?) Plain abdominal x-ray Colonoscopy, CT abdo, other?

12. Assessment of constipation History Examination Investigations With a view to making a diagnosis in order to safely manage symptoms

13. Older people and illness I More illnesses More functional impairment More medication Frail elderly have less reserve Non-specific presentation of illness

14. Older people and illness 2 More detective work required Small changes can make a big difference Very rewarding

15. 80 year old frail rest home resident Reports constipation over several months Bowel motions less often, some hard stools Abdominal and rectal exam normal No medication What next?

16. Afternoon tea

17. Mrs A aged 82 Constipation 5 months Urinary & faecal incontinence 3 months Weight loss 20kg No PR bleeding Past Hx: COPD, hypertension, osteoporosis, type 2 diabetes, forgetful last 1 year

18. More history Medications: diltiazem, celiprolol, quinapril, alendronate, inhalers, paracetamol Social: Lived with husband, independent simple ADL’s, low walking frame

19. Examination Distended abdomen Percussible bladder Dilated anus Perineum distended Rectum full of hard faeces

20. Case continued Bloods normal AXR some dilated bowel loops, faeces++ Diagnosis: faecal impaction IDC inserted Rx enemas, Coloxyl/senna, Movicol

21. Transfer to OPH Loose stools 1-2 daily, IDC still Abdomen soft, non-tender, bs normal PR hard faecal mass at finger tip Rx more enemas and movicol Loose stools 1-2 daily What next?

22. Case continued 2 Repeat AXR: still faeces ++ sigmoid Gastro review ? flexi sig or colonoscopy Declined, suggested high enema with Foley Good result, mass resolved

23. Case continued Loose stools 1-2/day, weary of movicol What next?

24. Encouraged self management To keep bowel diary MMSE 27/30

25. Case continued Unable to keep bowel diary ACE-R 74/100 (fluency 1/14 suggests impaired executive function) Discharged home once daily formed stool on Movicol 1 sachet daily with Coloxyl/senna if no motion that day Husband to keep bowel diary, Mrs A to use commode

26. Outcome 6 months later, doing well at home Bowels fine 10kg weight gain with food supplements Husband’s heart condition a problem, planning to move to retirement unit